Signing Up For Patient Reference Group

If you are happy for us to contact you periodically by email please fill out all
the fields below and send the completed form to us.

Title

MrMrsMissMs

First Name(s)

Surname

Email Address

Telephone

Postcode

Date of Birth

The information below will help to make sure that we receive feedback from a representative
sample of the patients registered at this practice.

Your Gender

Male

Female

Your Age

Under 16

17 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65 - 74

75 - 84

Over 84

The ethnic background with which you most closely identify is:

White

British Group

Irish

Mixed

White & Black CaribbeanWhite & Asian

White & Black African

Asian or Asian British

IndianBangladeshi

Pakistani

Black or Black British

Caribbean

African

Chinese or Other

Chinese

Any Other

How would you describe how often you come to the practice?

Regularly

Occasionally

Very Rarely

About This Form

Fields marked with a red asterisk arecompulsory.

Please note that we will not respond to any medical information or questions received
through the survey.

The information you supply us will be used lawfully, in accordance with GDPR Regulations. GDPR gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Please note that by using this form you will be sending information about yourself
across the Internet. Whilst every effort is made to keep this information secure,
you should be aware that we cannot offer any guarantees of absolute privacy. If
this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located
in the UK and is treated as confidential.